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abnormal uterine bleeding

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abnormal uterine bleeding

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    1. Abnormal Uterine Bleeding Hilary Suzawa Med/Peds March 2006

    3. Menstrual Cycle Follicular Phase—FSH increases causing dominant follicle to mature and produce estrogen in granulosa cells. Endometrium proliferates and positive feedback on LH Ovulatory Phase Luteal Phase—Progesterone increases and stops proliferation of endometrium. As progesterone falls, endometrium sheds

    4. Menstrual Abnormalities What is the normal length of menstrual cycle? 21-35 days; <21 days (polymenorrhea) or > 35 days (oligomenorrhea) is abnormal How long does menses normally last? 2-7 days; <2 days or > 7 days is abnormal What is considered heavy bleeding? More than 80 cc blood per cycle (menorrhagia)

    5. Childbearing Years Pregnancy Miscarriage/abortion, ectopic, placenta previa, abruption, trophoblastic dz Pelvic exam, UPT, B-hcg, pelvic U/S Iatrogenic Medications: anticoagulants, SSRIs, antipsychotics, corticosteroids, hormones, tamoxifen, ginseng, ginkgo, soy

    6. Childbearing Years Systemic Disorders Endocrine (thyroid, adrenal, pituitary, hypothalamic, PCOS, DM), hematologic, hepatic TSH, T4, LH, FSH, DHEA-S, testosterone, PRL, FBS, CBC, PT/PTT/INR, liver profile Genital Tract Fibroids, polyps, adenomyosis, endometrial hyperplasia and atypia, endometrial CA, infection Pelvic exam, PAP, cultures, U/S

    7. Childbearing Years Dysfunctional Uterine Bleeding—dx of exclusion Anovulatory DUB—disturbance of the HPO axis that results in irregular, prolonged and sometimes heavy menstrual bleeding. Immediately after menarche before maturation of HPO axis During peri-menopause Unopposed estrogen may lead to endometrial proliferation and hyperplasia Ovulatory DUB Polymenorrhea, oligomenorrhea, mid-cycle spotting, menorrhagia

    8. Endometrium Evaluation Transvaginal U/S—to evaluate “endometrial stripe.” What is normal size? Normal is <5 mm Endometrial Biopsy If PAP shows AGUS “atypical glandular cells of undetermined significance, favor endometrial origin” then perform endometrial biopsy ACOG recommends endometrial evaluation in women >= 35 years who have abnormal uterine bleeding Pt who continue bleeding abnormally despite medical tx Pt who are at high risk for endometrial CA

    9. Risks for Endometrial CA Anovulatory cycles Obesity Nulliparity Age >35 years h/o breast cancer Tamoxifen Diabetes FMH CA: endometrial, ovarian, breast, colon

    10. U/S and Biopsy Transvaginal U/S sensitivity for endometrial CA 96% and for endometrial abnormality 92% Endometrial biopsy sensitivity for endometrial abnormality as high as 96% May miss up to 18% of focal lesions because of sampling Sensitivity for endometrial hyperplasia as low as 81%

    11. Saline-infusion sonohysterography U/S done after 5-10 cc of sterile saline instilled into endometrial cavity More accurate than transvaginal U/S for dx intracavitary lesions More accurate than hysteroscopy in dx endometrial hyperplasia

    12. Dilation and curettage No longer considered therapeutic for abnormal uterine bleeding in most cases Offered to postmenopausal women with DUB who have been receiving hormone tx for more than 12 months

    14. Medical Management Anovulatory DUB OCP (30-35 mcg of ethinyl estradiol) What if OCP is contraindicated (eg. Smoker >35 years old and at risk for thromboembolism)? Cyclic progestins such as medroxyprogesterone acetate (5-10 mg) or norethindrone acetate (5-15 mg) for 5-12 days per month

    15. Medical Management Ovulatory DUB Menorrhagia NSAIDs such as mefenamic acid (Ponstel) Levonorgestrel-releasing intrauterine system (Mirena)—has been shown to decrease menstrual blood loss significantly Androgens (danazol) and GnRH agonists may be used for short-term endometrial thinning before ablation is performed Anti-fibrinolytics such as tranexamic acid—used infrequently b/c concern for risk of thromboembolism

    16. Surgical Managment When medical therapy fails or is contraindicated Hysterectomy for adenocarcinoma Consider hysterectomy if biopsy shows atypia Uterus-sparing surgical procedures

    17. Case 1 18 yo LAF presents with 3 year h/o irregular menses. Often skips a month of menses. Lasts 4-5 days. Changes pad 3x/day. Denies heavy bleeding or h/o anemia. Has recurrent yeast infections over past 2 years Height 5’2” and Weight 165 lbs Unremarkable exam except for acne on face and back

    18. Case 1 What do you want to do? CBC—shows no anemia FBS—122 Liver profile—ALT 65 and AST 78 Lipid profile—TG 234 LH/FSH ratio—ratio is 2.4 Consider DHEA-S, testosterone TSH and T4

    19. Case 1 What is your most likely diagnosis? Polycystic Ovarian Syndrome (PCOS) How would you treat this pt? Counsel about diet and exercise Start OCP Start Glucophage (Metformin) 500 mg po daily or BID Trial of diet for hyperTG but may need fibrate

    20. Case 2 43 yo AAF presents with h/o Fe-deficiency anemia and h/o heavy menses for past 3 years Pt reports that menses last 14 days and she changes pad 6-8 x/day and they are soaked Pt has two children, no pregnancy complications PE: HR is 115, pt slightly pale

    21. Case 2 What do you want to do? Check orthostatic vital signs CBC—shows Hb 9.5 with MCV 65 Fe studies—low Fe and ferritin Start OCP Transvaginal U/S—endometrial stripe 3 mm Endometrial biopsy

    22. Bibliography Albers J, Hull S, and Wesley R. Abnormal Uterine Bleeding. AAFP 2004; 69: 1915-26; 1931-2. Up to Date

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